In the Magazine

Health Care Reform: What Does It Mean for You?

The complex and controversial Affordable Care Act includes reforms that could benefit cancer patients and survivors.

by Bara Vaida

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The Affordable Care Act (ACA)—the health care reform law popularly called Obamacare—is expected to have a significant impact on cancer patients and survivors. The consumer protection changes in the law ensure that no one can be denied health insurance, regardless of medical history, and the law imposes new out-of-pocket limits that may reduce costs for many cancer patients and survivors.

Under the law, U.S. residents must obtain health insurance to avoid a tax penalty.
Cancer Today spoke with health care experts about what every cancer patient and survivor should keep in mind when considering insurance options. The important message is to look carefully at a plan’s benefits—a lot of variation exists in coverage and cost.

Besides guaranteed coverage, what are the benefits of the law? The law applies to all health insurance plans, whether purchased by an individual, offered through an employer or provided by Medicare or Medicaid. Among the reforms are:

An insurer cannot impose an annual or lifetime limit on how much it will pay for medical care.

There are caps on out-of-pocket costs, like deductibles, copays and coinsurance.

An insurer must pay for cancer screening tests, such as mammograms and colonoscopies, without charging a copay.

Routine medical care associated with participation in clinical trials must be covered by insurance.

A patient has the right to appeal to an insurer if denied payment for a service.

Children are allowed to stay on their parents’ plans until they turn 26.

Of all these changes, the most beneficial to cancer patients may be the ban on lifetime coverage limits, because “people with cancer can rack up significant bills,” says George Weiner, an internist and director of the Holden Comprehensive Cancer Center at the University of Iowa in Iowa City.

What are the new insurance marketplaces, and why buy insurance there? People who are uninsured, buy insurance on their own, can’t get insurance through an employer or find their employers’ insurance inadequate can go online to a marketplace to see and compare multiple insurance options and premiums. Purchasing insurance through the federal and state-run marketplaces (access to all the marketplaces can​ be found on
healthcare.gov) is the only way to obtain a federal tax credit to help offset the cost of premiums or get help with out-of-pocket costs. If you purchase insurance outside the marketplaces, no tax credit is available. Those wishing to buy insurance through the marketplaces this year must do so during the enrollment period, which ends on March 31.

Confused? Help Is Available

Resources are available to help you understand the health insurance process.

healthcare.gov and 1-800-318-2596 This is the official federal government website and help line for the Affordable Care Act (ACA).

Navigators and In-Person Assisters The federal government and state governments have given grants to organizations to answer questions by phone and sit down with consumers in person to help them select the right health plan.

Cancer Insurance Checklist Nineteen patient advocacy organizations created this site to help consumers consider their cancer needs and sort through insurance plan options on the health insurance marketplaces.

AARP This organization created a tool that generates a customized report on the impact of the health law based on an individual’s state of residence, gender, income, age and insurance status.

American Cancer Society Cancer Action Network This site has a page devoted to detailed fact sheets and background information on the health law for cancer patients and survivors. It also provides a checklist and tips for buying insurance.

The Kaiser Family Foundation This nonprofit health care think tank has an extensive guide to help consumers understand the health law, as well as a list of frequently asked questions and a calculator for determining health insurance tax credits.

Fraud Alert Scams often arise with new government programs. Here are tips on how consumers can protect themselves from fraud.

What do the plans cost? Plans are broken into tier levels—bronze, silver, gold and platinum—based on their cost and benefits. Bronze plan premiums are the cheapest, but these plans also have high deductibles, copays and coinsurance. Platinum premiums are the most expensive, but the plans have lower out-of-pocket costs. The Leukemia & Lymphoma Society advises that bronze coverage, although inexpensive, “is insufficient for patients with high-cost medical needs” and suggests that cancer patients purchase silver or higher tier plans. The American Cancer Society (ACS) Cancer Action Network says a gold or platinum plan may be “the better choice” for cancer patients, as does the federal government. There is also a catastrophic tier, aimed at people under 30 and those who qualify for a hardship exemption, that features very high deductibles and is essentially a safety net for people who experience serious health events such as accidents or extended illness. The hardship exemption includes people whose health insurance has been canceled and who can’t afford to enroll in one of the four standard tiers.

How much will tax credits subsidize premium costs? It depends on income and family size. For example, an individual with an annual income up to $45,960 and a family of eight with an income up to $158,520 may be eligible for a tax credit.

What benefits are available in marketplace insurance plans? All of the plans sold must cover 10 essential benefits: ambulatory patient services (outpatient care), emergency services, hospital care, maternity and newborn care, mental health and substance use services, prescription drugs, rehabilitative and habilitative services, laboratory services, preventive services and chronic disease management, and pediatric care, according to the Department of Health and Human Services.

Are palliative care and hospice care covered? It depends. Palliative care and hospice care are classified as a benefit under “ambulatory services,” but each state and insurance plan can decide how that benefit is met, according to Kirsten Sloan, the senior director of policy analysis and legislative support at the ACS’s Cancer Action Network.

Can people visit any doctor, specialist, hospital or treatment center, no matter where they are in the country? It depends on the plan. Every plan in the marketplace must provide a list of doctors and hospitals in the plan. If a doctor or hospital you want is not on the list, the plan may not be the right one to buy. Many top cancer centers aren’t participating in all of the marketplace plans. Some plans may allow people to see doctors or visit hospitals outside the network, but they may charge patients more to do so, says Sloan. “This is why we encourage people not to just look at premiums but to also look at copays and deductibles” when picking a plan.

Are all cancer drugs covered? No. All plans must provide a formulary, or list of drugs covered, but not all cancer drugs are included in every plan, says Brian Rosen, the senior vice president of public policy at the Leukemia & Lymphoma Society. Further, out-of-pocket costs for cancer drugs will be higher in some states than in others. In New York, for example, no patient will pay more than $70 for a cancer drug in a formulary. In Connecticut, patients may be responsible for 50 percent of the cost of drugs, according to the ACS’s analysis of several state health care insurance marketplace plans.

Are there limits on out-of-pocket costs under the law? It depends on the plan. The law sets an annual out-of-pocket cap of $6,350 for an individual plan and $12,700 for a family plan. However, some plans can set separate out-of-pocket limits for medical expenses and drug coverage if the plans use separate administrators for these benefits. This exception, which will end in 2015, could mean beneficiaries pay more out-of-pocket in 2014. Additionally, it’s important to know that some plans may count deductibles, copays and coinsurance toward the out-of-pocket cap and others may not. Premiums do not count toward out-of-pocket costs for any plan.

Is there a way to get help with out-of-pocket costs? By purchasing a mid-range silver plan through the marketplace, individuals with an income up to $28,725 and a family of eight with an income up to $99,075 may be eligible for a further reduction in the out-of-pocket maximum. This benefit is available only for those who enroll in a silver plan, according to the Department of Health and Human Services. For example, a family of four in a silver plan with an income of $23,550 in 2013 would pay just 6 percent of covered expenses out-of-pocket instead of the 30 percent a family in a silver plan without subsidized coverage would have to pay.

How does the law affect employer-sponsored insurance? All of the consumer protections laid out in the law apply to employer-sponsored insurance. Beginning in 2015, employers with 50 or more full-time employees must provide health insurance or pay a penalty. Companies with fewer than 50 employees are not required to offer coverage. However, a company with fewer than 50 employees that provides insurance for employees through the marketplace beginning in 2015 may be eligible to receive a tax credit for insuring those people.

If an employee has to pay more than 9.5 percent of family income for employee-sponsored health insurance or the insurance pays less than 60 percent of a typical employee’s covered expenses, the employee may shop for insurance in the marketplace and the company will pay a penalty, according to the Kaiser Family Foundation.

What is a “grandfathered” health plan? Companies that bought insurance before March 23, 2010, and made no substantial changes are “grandfathered,” meaning they are exempt from some of the ACA rules that could benefit cancer patients and survivors. Examples include the requirements that health insurance offer free preventive services and cover routine costs related to participating in clinical trials. Grandfathered plans also don’t have to guarantee the right to appeal an insurance denial, can limit where a beneficiary goes for emergency care services, and aren’t subject to premium-rate reviews.

Self-insured plans, in which companies fund insurance benefits themselves, also are exempt from a few of the rules. They aren’t subject to an annual rate review and don’t have to report how much of a premium goes to pay medical costs. They also don’t have to guarantee coverage or cover the 10 essential benefits described earlier.

Are there any other exceptions to these rules? Health insurance plans sold to indi​viduals before March 23, 2010, may also be “grandfathered” and do not have to comply with all of the consumer protection rules. Most notably, these plans may still impose annual and lifetime limits on covering medical care, and they can deny coverage for a pre-existing condition.

How does this law affect cancer patients with Medicare and Medicare supplemental insurance? Current Medicare beneficiaries don’t need to do anything to maintain their health care coverage. Benefits are still guaranteed. Beneficiaries still buy insurance at
medicare.gov or by calling 1-800-MEDICARE (1-800-633-4227), and they can update their plan during Medicare’s annual open enrollment period. They cannot buy insurance through the ACA marketplace. The law also makes no changes to Medicare supplemental insurance, says Nicole Duritz, the vice president of health education and outreach for AARP, the seniors advocacy organization based in Washington, D.C.

New Medicare beneficiaries have been eligible for one free physical. Under the ACA, beneficiaries can also have an annual free wellness visit with their physician. Further, certain cancer screening services, like mammograms and colonoscopies, are covered without a copay, Duritz says, but she recommends patients talk to their doctor before any screening to avoid billing surprises.

How does the law affect drug coverage for Medicare beneficiaries? The law lowers the cost of prescription drugs by shrinking the coverage gap (the “doughnut hole”) for drugs. In 2014, beneficiaries pay 25 percent of the cost of prescription drugs until the total amount the beneficiary and the insurance plan pay reaches $2,850. Then there is a gap in coverage until a beneficiary’s out-of-pocket spending on these drugs hits $4,550. Under the law, Medicare beneficiaries will get a discount for drugs during that gap in coverage. In 2014, the discount is 52.5 percent for brand-name drugs and 28 percent for generic drugs. By 2020, there will be no gap in coverage, according to the federal government.

How does the law affect those who receive coverage through Medicaid? In 25 states and the District of Columbia, the Medicaid program has expanded to allow some low-income adults who were not previously eligible to now qualify for health insurance under Medicaid. In those states, adults with incomes up to $15,856 and families of three with incomes up to $26,951 will be able to get Medicaid, according to the Kaiser Family Foundation. Medicaid must cover the same essential health benefits as those available through plans in the health insurance marketplace.

Bara Vaida is a freelance health care writer based in Washington, D.C.